The nurse is providing discharge teaching to a postpartum patient. Which information will the nurse include when teaching the parent about the difference between pathologic and physiologic jaundice?

Pathologic jaundice appears within 24 hours after birth.

Both are treated with exchange transfusions of maternal O-negative blood.

Physiologic jaundice results in kernicterus.

Physiologic jaundice requires transfer to the neonatal intensive care unit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pathologic jaundice is an abnormal condition that typically appears within the first 24 hours of life. It often indicates an underlying health problem and requires prompt medical evaluation and intervention.

Choice B reason: Both pathologic and physiologic jaundice are not treated with exchange transfusions of maternal O-negative blood. Exchange transfusions are only considered in severe cases of jaundice, typically for pathologic jaundice when other treatments are ineffective.

Choice C reason: Physiologic jaundice is a common and usually harmless condition that occurs in many newborns, peaking around the second or third day of life. It does not result in kernicterus, a rare but severe form of brain damage caused by very high levels of bilirubin. Pathologic jaundice, if untreated, may lead to kernicterus.

Choice D reason: Physiologic jaundice generally does not require transfer to the neonatal intensive care unit. It is usually managed with simple interventions, such as phototherapy, and often resolves on its own as the newborn's liver matures and becomes more efficient at processing bilirubin.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Having the patient sit on the side of the bed before standing is crucial to prevent dizziness or fainting, especially after giving birth. This intervention allows the patient to stabilize and ensures that they do not experience sudden drops in blood pressure, which can lead to falls.

Choice B reason: Walking alongside the patient to the bathroom is important to provide support and ensure their safety. The patient may still be weak or unsteady after giving birth, and having the nurse nearby can help prevent falls and provide assistance if needed.

Choice C reason: Obtaining an oral temperature is not immediately necessary when assisting a patient to the bathroom post-vaginal birth. While monitoring vital signs is important, this intervention does not directly contribute to the immediate need for safe ambulation.

Choice D reason: Assessing for sensation in the lower extremities is essential to ensure that the patient has regained feeling and control in their legs. This assessment helps to determine if there are any residual effects from epidural anaesthesia or other factors that may affect mobility and safety.

Choice E reason: Assessing bowel sounds and passing flatus is important for overall postpartum care but is not directly related to assisting the patient to the bathroom. This intervention is more relevant to monitoring gastrointestinal recovery and function after childbirth.

Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

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The nurse is providing discharge teaching to a postpartum patient. Which information will the nurse include when teaching the parent about the difference between pathologic and physiologic jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

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